Chelsea Polis, senior epidemiological advisor at USAID, has considered more questions surrounding hormonal contraception and HIV than most people know even exist.

Does the use of injectable hormonal contraceptives increase the risk of a woman acquiring HIV?

If a woman has HIV, does her use of an injectable hormonal contraceptive increase the risk that her uninfected male sexual partner will get HIV?

Does using a hormonal contraceptive affect the progress of a the virus in a woman with HIV?

And, do hormonal contraceptives clash with antiretroviral drugs?

Speaking today with HIV and family planning advocates in Washington, DC, Polis said the one simple answer is this: “We may have no answer for some time,” she said. “Some might argue we may never have a clear answer.”

USAID’s recent systematic review of hormonal contraceptive studies found one that showed using DMPA, the most common injectable hormonal contraceptive, did appear to increase a woman’s risk of HIV acquisition — but also found the data short of clearly conclusive. It found a study showing a slightly increased risk of female-to-male HIV transmission with the use of DMPA, while other data did not. And to complicate things further, one study showed the possibility that for women living with HIV, using DMPA appeared to slow progression of the disease. Add to that, that injectable hormonal contraception, is the most widely used method in Southern Africa — which also happens to be the place with the world’s highest HIV incidence. And, that with at least 86 million unintended pregnancies each year globally, it still is unknown with certainty if pregnancy itself increases the risk of HIV acquisition.

“It gets complicated,” Polis said.

The number of questions and the shortage of answers leaves, she says, “a public health conundrum”

Reducing injectable hormonal contraceptive use may reduce HIV infections but will also increase maternal mortality, Polis said, but she added, “we are comparing deaths to deaths.”

But, “a lot more goes on,” she said, in impacts to women’s health both from unintended pregnancies and complications from childbirth and from HIV.

Injectable hormonal contraceptives are the most successful family planning methods in limited resource settings where traditionally women do not have much agency over their sexual and reproductive health needs, Polis said.

Because the data does not conclusively show that there is a causal link between injectable contraceptives and HIV acquisition, last year the World Health Organization decided not to change guidelines on contraceptive use, but also recommended that women at high risk for HIV acquisition who take Depo Provera and other injectables should be strongly advised to always use condoms and employ other HIV preventative measures.

So what to do in what she calls “a context of uncertainty?”

That is a question she can answer.

Ensure women have the information and the resources they need, she says, including expanding the mix of available contraception, increasing access to HIV testing, and find ways to encourage women to use more than one method of contraception.

Get more data.

Develop multi-purpose technologies.

And she says, build shared trust and understanding to deliver what is best for women and girls.

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